RSA 227 CAP Report

FORM RSA-227 OMB NO. 1820- 0528

EXPIRES:

ANNUAL CLIENT ASSISTANCE PROGRAM (CAP) REPORT

Fiscal Year

DESIGNATED AGENCY IDENTIFICATION

Name:

Address:

E-mail Address (if applicable):

Website Address (if applicable):

Phone:

Toll-free Phone:

TTY:

Fax:

OPERATING AGENCY (IF DIFERENT FROM DESIGNATED AGENCY)

Name:

Address:

E-mail Address (if applicable):

Website Address (if applicable):

Phone:

Toll-free Phone:

TTY:

Fax:

Name of CAP Director/Coordinator:

Person to contact regarding report:

Contact Person's phone:

PART I. NON-CASE SERVICES

A. Information and Referral Services (I&R):

(Multiple responses are not permitted.)

1. Information regarding the vocational rehabilitation (VR) program

2. Information regarding independent living programs

3. Information regarding American Indian VR Service projects ______

4. Information regarding Title I of the ADA

5. Other information provided

6. Information regarding CAP

7. Total I&R services provided (Lines A1through A6)

B. Training Activities

1. Number of training sessions presented to community groups

and public agencies.

2. Number of individuals who attended these training sessions

3. Describe training presented by the staff. Include the following information:
(a) topics covered
(b) the purpose of the training
(c) a description of the attendees

C. Agency Outreach

Describe the agency’s outreach efforts to previously un-served or underserved individuals including minority communities

D. Information Disseminated To The Public By Your Agency

For each method of dissemination, enter the total number of each method used by your agency during the reporting period to distribute information to the public. For publications/booklets/brochures (item 4), enter the total number of documents produced. Agencies should not include website hits. See instructions for details

1. Agency Staff Interviewed or Featured on Radio and TV

2. Articles about CAP Featured in Newspaper/Magazine/Journals

3. PSAs/Videos Aired about the CAP Agency

4. Publications/Booklets/Brochures Disseminated by the Agency

5. Number of Times CAP Exhibited at Conferences, Community Fairs, etc.

6. Other (specify below)

E. Information Disseminated About Your Agency By External Media Coverage

Describe the various sources and information disseminated about your agency by an external source.

PART II. INDIVIDUAL CASE SERVICES

A. Individuals served

An individual is counted only once during a fiscal year. Multiple counts are not permitted for Lines A1-A3.)

1. Individuals who are still being served as of October 1 (carryover from prior year)

2. Additional individuals who were served during the year

3. Total individuals served (Lines A1+A2)

4. Individuals (from Line A3) who had multiple case files opened/closed this year (In unusual situations, an individual may have more than one case file opened/closed during a fiscal year. This number is not added to the total in Line A3 above.)

5. Individual still being served as of September 30 (Carryover to next year. This total may not exceed Line A3.)

B. Problem areas (Multiple responses permitted.)

1. Individual requests information

2. Communication problems between individual and VR counselor

3. Conflict about VR services to be provided

4. Related to VR application/eligibility process

5. Related to assignment to order of selection priority category

6. Related to IPE development/implementation

i. Selection of vendors for provision of VR services

ii. Selection of training services, including postsecondary education

iii. Selection of employment outcome

iv. Transition services

7. Related to independent living services

8. Other Rehabilitation Act-related problems

9. Non-Rehabilitation Act related

i. TANF

ii. SSI/SSDI

iii. Housing

iv. Other:

10. Related to Title I of the ADA

C. Intervention Strategies for closed cases

(Choose one primary service the CAP provided for each closed case file. There may be more case files than actual individuals served.)

1. Short Term Technical Assistance

2. Investigation/Monitoring

3. Negotiation

4. Mediation and other methods of Alternative Dispute Resolution

5. Administrative / Informal Review

6. Formal appeal / Fair Hearing

7. Legal remedy / Litigation

8. Total

D. Reasons for closing individuals’ case files

(Choose one primary reason for closing each case file. There may be more case files than the total number of individuals served.)

1. All issues resolved in individual’s favor

2. Some issues resolved in individual’s favor (when there are multiple issues)

3. CAP determines VR agency position/decision was appropriate for the individual

4. Individual’s case lacks legal merit; (inappropriate for CAP intervention)

5. Individual chose alternative representation

6. Individual withdrew complaint

7. Issue not resolved in clients favor

8. CAP services not needed due to individual’s death, relocation, etc.

9. Individual not responsive/cooperative with CAP

10. CAP unable to take case due to lack of resources

11. Conflict of interest

12. Other (Please explain below)

E. Results achieved for individuals

(Choose one primary outcome for each closed case file. There may be more case files than the total number of individuals served.)

1. Controlling law/policy explained to individual

2. Application for services completed

3. Eligibility determination expedited

4. Individual participated in evaluation

5. IPE developed/implemented/Services Provided

6. Communication re-established between individual and other party

7. Individual assigned to new counselor/office

8. Alternative resources identified for individual

9. ADA/504/EEO/OCR complaint made

10. Other (specify below)

PART III.PROGRAM DATA

A. Age (Multiple responses not permitted.)

1. Up to 18

2. 19 - 24

3. 25 - 40

4. 41 - 64

5. 65 and over

6. Total (Sum of Lines A1 through A5. Total must equal Part II, Line A3.)

B. Gender (Multiple responses not permitted.)

1. Females

2. Males

3. Total (Lines B1+B2. Total must equal Part II, Line A3.)

C. Race/ethnicity of Individuals Served

1. Hispanic/Latino of any race
For individuals who are non-Hispanic/Latino only

2. American Indian or Alaskan Native

3. Asian

4. Black or African American

5. Native Hawaiian or Other Pacific Islander

6. White

7. Two or more races

8. Race/ethnicity unknown

D. Primary disabling condition of individuals served (Multiple responses not permitted.)

1. Acquired Brain Injury

2. ADD/ADHD

3. AIDS/HIV

4. Amputations or Absence of Extremities

5. Arthritis or Rheumatism

6. Anxiety Disorder

7. Autism Spectrum Disorder

8. Autoimmune or Immune Deficiencies (excluding AIDS/HIV)

9. Blindness (Both Eyes)

10. Other Visual Impairments (Not Blind)

11. Cancer

12. Cerebral Palsy

13. Deafness

14. Hard of Hearing/ Hearing Impaired (Not Deaf)

15. Deaf-Blind

16. Diabetes

17. Digestive Disorders

18. Epilepsy

19. Heart & Other Circulatory Conditions

20. Intellectual Disability

21. Mental Illness

22. Multiple Sclerosis

23. Muscular Dystrophy

24. Muscular/Skeletal Impairment

25. Neurological Disorders/Impairment

26. Orthopedic Impairments

27. Personality Disorders

28. Respiratory Disorders/Impairment

29. Skin Conditions

30. Specific Learning Disabilities (SLD)

31. Speech Impairments

32. Spina Bifida

33. Substance Abuse (Alcohol or Drugs)

34. Other Disability

35. Total (Sum of Lines D1through D34. Total must equal Part II, Line A3.)

E. Types of Individuals Served (Multiple responses permitted)

1. Applicant of VR

2. Individual eligible for VR services currently on a wait list

3. Individual eligible for VR services not currently on a wait list

4. Applicant or individual eligible for Independent living

5. Transition student/High school student

6. All other applicants or individuals eligible for other programs or projects funded under the Rehabilitation Act.

PART IV. SYSTEMIC ACTIVITIES AND LITIGATION

A. Non-Litigation Systemic Activities

1. Number of non-litigation systemic activities not involving individual representation that resulted in the change of one or more policy or practice of an agency.

2. Describe the systemic activities conducted by CAP during the fiscal year and its impact on other agency’s policies or practices.

B. Litigation

1. Total number of CAP cases requiring litigation involving individual representation resulting in, or with the potential for, systemic change.

a. Number of cases requiring litigation involving individual representation filed during fiscal year.

b. Number of on-going cases pending at start of fiscal year (carryover from prior fiscal year).

c. Number of cases resolved through litigation during fiscal year.

2. Describe the agency’s on-going and completed systemic litigation activities involving individual representation.

PART V. AGENCY INFORMATION

A. Designated Agency

A. Agency Type (check only one option for Lines 1.a through 1.e)

a. Internal to the State VR agency

b. External-other public agency

c. External-Protection and Advocacy agency

d. External-other nonprofit agency

e. External-all other private agencies

B. Name of designate agency

C. Is the designated agency contracting CAP services? Yes/No

D. If yes, name of contracting agency:

B. Staff Employed

Provide a description of all CAP positions (see instructions)

PART VI. CASE EXAMPLES

Provide some examples of some interesting cases during the past fiscal year

Reports are to be submitted to RSA within 90 days after the end of the fiscal year covered by this report. Please be reminded that you can enter data directly into RSA’s website via the Internet. Information on transmittal of the form is found on pages 19 and 20 of the reporting instructions.

Signature and title
of designated agency official

Date

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